To C-Spine or Not to C-Spine. Kevin Parkes, M.D.
Disclosures: None!
Warning! This one is tough Get ready to rethink your training!! Mechanism of Injury.. Remember CPR ABC
Pediatric issues General spinal precaution lecture Discussion important here Peds differences Age Anatomy Studies
Two Different Questions Spinal precautions Things have changed Lots to consider Spinal clearance We will touch on this first
Spinal Clearance In selected patients: Allows us to eliminate ANY spinal precautions Safe Validated Just have to follow the rules We use daily in the ED Valuable tool
Spinal Clearance Good evidence for this. NEXUS (National Emergency X-Radiography Utilization Study) CCR (Canadian C-Spine Rules)
Canadian C-spine Rules
Canadian C-spine Rules No patients under 16 Good for adults Not applicable to pediatric patients
NEXUS (2000) There is no posterior midline cervical tenderness There is no evidence of intoxication The patient is alert and oriented to person, place, time, and event There is no focal neurological deficit There are no painful distracting injuries (e.g., long bone fracture)
What About Peds? Can we use NEXUS? Pediatric Subset: Viccellio et al 2001 A few numbers: 34,069 total patients in NEXUS 3065 children < 18yrs 603 low risk 100% negative x-rays 30 with CSI 100% detected by NEXUS Only 4 CSI < 9 yrs old Number of young kids is too small Would take 80,000 children in a study to reach acceptable CI
What About Peds? Go to the experts: American Association Of Neurological Surgeons recommend application of NEXUS criteria for children >9yrs Viccellio: Use NEXUS 12 or older NEXUS Pediatric Study: OK to use with younger kids Pediatric Emergency Care Applied Research Network (PECARN)
Enhanced Pediatric Clearance Pediatric Emergency Care Applied Research Network (PECARN) 540 children with trauma/ total 1774 controls Eight factors identified altered mental status focal neurologic findings neck pain torticollis substantial torso injury conditions predisposing to cervical injury ie Down Syndrome diving high risk MVA
Enhanced Peds Clearance Conclusion : would have detected 98% CSI ; Reduced exposure to spinal immobilization Reduce ionizing radiation for non CSI children by more than 20%
What should we do? Let s stop for a second Why does age matter?
Pediatric Spinal Injuries Low incidence National Trauma Registry avg 100 new cases per year 1.5% blunt trauma patients 35% with cord injury Higher mortality < 8 years 2/3 above C3
Pediatric C-spine injuries
Pediatric C-spine injuries Young children s: Heads are relatively Bigger Heavier Necks are weaker Spinal canals are smaller Facets are flatter Ligaments are more lax
Pediatric C-spine injuries Bigger, heavier head = higher fulcrum Area where greatest force is applied Explains more common C2C3 injuries Craniocervical junction is more vulnerable Weaker muscles = less ability to protect Smaller canal = easier to shear Facets are flatter = easier for vertebra to move Ligamentous laxity = less boney stability SCIWORA
Vertebra
Spinal ligaments
Spinal column
Spinal column
SCIWORA Bones look OK Neck flexed enough to cause cord injury without bone injury +/- ligamentous disruption Neuro deficit Can be transient Can return with later swelling Happens in adults too but usually considered with kids
What should we do? Room for debate, but: NEXUS criteria can cautiously be applied to patients older than 8 Younger children cannot be cleared based on NEXUS alone. Enhanced clearance can be considered
What are Spinal Precautions? C-collars Long board Straps Head Bed or blocks Tape Maybe a KED or short board
What are our goals: Questions to answer: What is best for our patients? What method of extrication causes the least spinal movement? What method of transport is most appropriate for potential spinal? Do current treatments cause any harm? Does age matter? Does what we do work? Is there a better way?
Remember! I am NOT saying that protecting the spine is not important I AM saying we need to look at the best way to treat each patient One size won t fit all
Dogma Mechanism = Injury = Instability so Movement = Paralysis = Bad Full c-spine precautions prevent this = Protect the patient (and us )
Where did this come from: Initially, longboard was used to transport people WW2 It was practical and made sense Immobilization was not the goal
Where did this come from: 60 s Farrington Boards good because patients don t sag. Movement device, not long term immobilization Geisler Surgeon Delayed paralysis in skull fx patient faulty handling
Where did this come from: 70 s Longboards were adopted as useful devices Idea of underappreciated injuries led to longboards for ANY mechanism 80 s Regardless of symptoms The idea of occult injury leads to full precautions on everyone based on mechanism
Where did this come from: Studies showing benefit Before? Since? No randomized, controlled trials have shown longboards and full spinal immobilization to be beneficial No studies show that patients do better because of long boards Hmmm
What DO the studies show? Younger kids Older kids and adults
Younger Kids
Younger Kids
Younger Kids
Younger Kids Cannot adequately be cleared There is not enough research yet Peds boards
Peds Boards
Peds Boards
Younger kids Cannot adequately be cleared There is not enough research yet Peds boards Soft Anatomically appropriate
Younger kids Cannot adequately be cleared There is not enough research yet Peds boards Soft Anatomically appropriate Car seats
Younger kids Cannot adequately be cleared There is not enough research yet Peds boards Soft Anatomically appropriate Car seats Appropriate c-collars
Younger kids Cannot adequately be cleared There is not enough research yet Peds boards Soft Anatomically appropriate Car seats Appropriate c-collars Keep in mind the principles we are going to discuss
Spinal Precautions Older kids Adults
What DO the studies show? Lets ask some specific questions: Do long boards work? Do they stabilize the spine? Do they help with extrication? Do long board cause damage? How do we answer our questions? Evidence based Lets look at the literature What do the experts say?
Lets start with EMS Journals Growing trend across the country to critically evaluate backboards and spinal immobilization More and more publications are supporting paradigm change Most quote studies and position papers
What do the Societies say NAEMSP ATLS/PHTLS Cochran Review The Eagles And Hauswald
NAEMSP Although early emergency medical literature identified mishandling of patients as a common cause of iatrogenic injury, these instances have not been identified anywhere in the peer-reviewed literature and probably represent anecdote rather than science.
PHTLS Position There is no data to support spine immobilization in patients with penetrating trauma to the neck or torso There are no data to support routine spinal immobilization in patients with isolated penetrating trauma to the cranium 2011
Cochrane Review Unwarranted spinal immobilization can expose patients to risk of iatrogenic pain, skin ulceration, aspiration and respiratory compromise The potential risks of aspiration and respiratory compromise are of concern because death from asphyxiation is one of the major causes of preventable death in trauma patients. 2009
US Consortium of Metropolitan Medical Directors The Eagles Current best practices reflect that there are no randomized controlled trials to evaluate the benefits of spinal immobilization in out-of-hospital trauma patients. current EMS protocols are based principally on historical precedent, dogma and medico-legal concerns, and not on scientific evidence There is, however, a growing body of literature that points to the potential deleterious effects of spinal immobilization. 2009
The Literature Hauswald Compared spinal injury patients in New Mexico vs. Malaysia Huh??
Out-of-hospital Spinal Immobilization: Its Effect on Neurologic Injury 2 Mark Hauswald, MD, Gracie Ong, MBBS, Dan Tandberg, MD, Zaliha Omal; MBBS 1998 Objective: To examine the effect of emergency immobilization on neurologic outcome of patients who have blunt traumatic spinal injuries. Methods: A 5-year retrospective chart review was carried out at 2 university hospitals. All patients with acute blunt traumatic spinal or spinal cord injuries transported directly from the injury site to the hospital were entered. None of the 120 patients seen at the University of Malaya had spinal immobilization during transport, whereas all 334 patients seen at the University of New Mexico did. The 2 hospitals were comparable in physician training and clinical resources. Neurologic injuries were assigned to 2 categories, disabling or not disabling, by 2 physicians acting independently and blinded to the hospital of origin. Data were analyzed using multivariate logistic regression, with hospital location, patient age, gender, anatomic level of injury, and injury mechanism serving as explanatory variables. Results: There was less neurologic disability in the unimmobilized Malaysian patients (OR 2.03; 95% CI 1.03-3.99; p = 0.04). This corresponds to a ~ 2% chance that immobilization has any beneficial effect. Results were similar when the analysis was limited to patients with cervical injuries (OR 1.52; 95% CI 0.64-3.62; p= 0.34).
The Literature Hauswald Compared spinal injury patients in New Mexico vs. Malaysia New Mexico = all patients c-spined Malaysia = no patients c-spined So? 334 pts immobilized, 120 pts not immobilized Immobilized 21% significant morbidity Non-immobilized 11% significant morbidity At best: Not helping At Worst: Doing harm?
The Literature What about peds? Leonard 2012 Longboards assoc. with: Increased pain Increased xray usage Increased admissions EMS has impact on hospital behavior
The Literature Penetrating trauma There are a number of studies that demonstrate spinal immobilization in penetrating trauma doubles mortality Who agrees?
The Literature Penetrating trauma There are a number of studies that demonstrate spinal immobilization in penetrating trauma doubles mortality AANS, ACS COT, NAEMSP, ATLS/PHTLS Should we pay attention?
A re-conceptualization of acute spinal care. Hauswald M. Emerg Med J. 2013 Sep;30(9):720-3. doi: 10.1136/emermed-2012-201847. Epub 2012 Sep 8. Abstract The emergency care of patients who may have spinal injuries has become highly ritualized. There is little scientific support for many of the recommended interventions and there is evidence that at least some methods now used in the field and emergency department are harmful. Since prospective clinical trials are not likely to resolve these issues I propose a reconceptualization of spinal trauma to allow a more rational approach to treatment. To do this I analyze the basic physics, biomechanics and physiology involved. I then develop a list of recommended treatment variations that are more in keeping with the actual causes of post impact neurological deterioration than are current methods. Discarding the fundamentally flawed emphasis on decreasing post injury motion and concentrating on efforts to minimize energy deposition to the injured site, while minimizing treatment delays, can simplify and streamline care without subjecting patients to procedures that are not useful and potentially harmful. Specific treatments that are irrational and which can be safely discarded include the use of backboards for transportation, cervical collar use except in specific injury types, immobilization of ambulatory patients on backboards, prolonged attempts to stabilize the spine during extrication, mechanical immobilization of uncooperative or seizing patients and forceful in line stabilization during airway management.
Lots of people lined up against backboards
Physics very briefly The spine can absorb large amounts of energy The spinal will fail at a certain energy level Trauma applies energy to the spine The amount of energy applied by standing, moving, etc. are extremely small Lets say someone fell 5 stories onto their head If they are paralyzed, then what? What is done, is done
Physics very briefly What if they aren t paralyzed? If the spinal cord wasn t injured in the event, we are not going to injure the spinal with controlled movement within the normal range of motion. Energy is the culprit If it hurts, patients don t move it. This is a key point!
Physics very briefly Penetrating trauma Extremely high energy injuries If they are paralyzed, it is final 2006 57,000 patient study. No patient with penetrating cord injury regained function If they are not paralyzed, your controlled movement will not hurt them However Delay in transport, difficulty managing airway, aspiration, respiratory compromise may kill the patient
So what is wrong with a backboard? Do they work?? Does it stabilize? Is anything better KED? Short board? Does it cause harm? Respiratory Skin Time Downstream
Does it stabilize? Is the spine straight? How would a hard, flat board help? Low friction Hard
Does it stabilize? Is the spine straight? How would a hard, flat board help? Low friction Hard
Does it stabilize?
What about lateral movement? Strap them down Mazolewski, 1994 All patients place on board and strapped down could move. What happens when you are uncomfortable? You wiggle
Straps The tighter the better Decrease FVC and FEV1 (measures of respiratory function) by 15% This is in healthy subjects What about the sick or injured ones??
Patient Harm Respiratory compromise Ischemic damage to tissue 20 minutes in elderly What about paralyzed patient What was the benefit that outweighed the risk? Excess xrays Especially a problem in peds Brain Thyroid Increased admission rate
What is wrong with a backboard? Seems as though there are a number of issues If it helps during extrication, though
What about extrication? Four techniques: The patient exits the vehicle on their own and lies down on the back board The patient exits the vehicle with a c-collar on and lies down on the board The patient is extricated head first using standard technique by two paramedics with a c-collar alone The patient is extricated head first using standard technique by two paramedics with a c-collar and a KED
Results??
Results?? Ultimately, we documented the least movement of the cervical spine in subjects who had a c-collar applied and were allowed to simply get out of the car and lie down on a stretcher.
Extrication 2 merg Med J doi:10.1136/emermed-2013-202500 Biomechanical analysis of spinal immobilization during prehospital extrication: a proof of concept study Mark Dixon 1, 2, Joseph O'Halloran 3, Niamh M Cummins 1 +Author Affiliations 1 Centre for Prehospital Research, Graduate Entry Medical School, University of Limerick, Limerick, Ireland 2 Centre for Emergency Medical Science, School of Medicine & Medical Sciences, University College Dublin, Dublin, Ireland 3 Department of Physical Education and Sport Sciences, University of Limerick, Limerick, Ireland Correspondence to Mark Dixon, Centre for Emergency Medical Science, School of Medicine and Medical Sciences, University College Dublin, Belfield, Dublin, Ireland; mark.dixon@ucd.ie Received 12 February 2013 Revised 4 June 2013 Accepted 6 June 2013 Published Online First 28 June 2013 Abstract Background In most countries, road traffic collisions (RTCs) are the main cause of cervical spine injuries. There are several techniques in use for spinal immobilisation during prehospital extrication; however, the evidence for these is currently poor. Objective The objective of this study is to establish which technique provides the minimal deviation of the cervical spine from the neutral inline position during the extrication of the RTC patient using biomechanical analysis techniques. Methods A crew of two paramedics and four fire-fighter first responders extricated a simulated patient from a prepared motor vehicle using nine different extrication techniques. The patient was marked with biomechanical sensors and relative movement between the sensors was captured via high speed infrared motion analysis cameras. A 3D mathematical model was developed from the recorded movement. Results Control measurements were taken from the patient during self-extrication and movement was recorded of 4.194 left of midline (LOM) to 2.408 right of midline (ROM) resulting in a total movement of 6.602. The least deviation recorded during equipment aided extrication was movement of 3.365 LOM and 8.352 ROM resulting in a total movement of 11.717. The most deviation recorded during equipment aided extrication was movement of 1.588 LOM and 24.498 ROM resulting in a total movement of 26.086. Conclusions Conventional extrication techniques record up to four times more cervical spine movement during extrication than controlled self-extrication. This proof of concept study demonstrates the need for further evaluation of current rescue techniques and the requirement to investigate the clinical and operational significance of such movement.
Extrication Methods: A crew of two paramedics and four fire-fighter first responders extricated a simulated patient from a prepared motor vehicle using nine different extrication techniques. The patient was marked with biomechanical sensors and relative movement between the sensors was captured via high speed infrared motion analysis cameras. A 3D mathematical model was developed from the recorded movement.
Extrication Conclusions: Conventional extrication techniques record up to four times more cervical spine movement during extrication than controlled self-extrication.
Uncooperative Patient Uncooperative patient Forcefully holding head down while the patient resists Physics Rescuer and patient head vs. body Where is the fulcrum?? Hauswald again 2012 forced immobilization worse than none Reasonable for crew safety, though
So what have we seen? There is no proven benefit to long board use for spinal stabilization Long boards: Do not conform to the spine Lateral stability is poor In conjunction with straps, attempting to limit lateral motion negatively impacts respiratory function Cause pain and discomfort Can cause ischemic damage and ulceration
So what have we seen? Spinal precautions as currently practiced: INCREASE movement during extrication Worsen outcome in penetrating trauma. Period May cause more harm to uncooperative patients
What should we do??
Disclosure! This is a discussion about the current, evidence-based patient care I am not advocating you disregard you local protocols I do want you to be aware of the direction emergency care is moving and why
What should we do? First, this is what I am NOT saying: I am not suggesting vigorous movement of patients with potential spinal injuries I am not saying to ignore spinal injuries I am not saying never to use a board Transportation device Scoop stretchers! I am not saying one size fits all
What should we do? Younger kids Minimize movement Use age and size appropriate immobilization devices Consider general principles we have discussed Agreement at local level Anxiously look forward to new data
What should we do? The rest?
What should we do? Allow ambulatory patients to perform controlled selfextrication There are good studies that show this decreases patient spinal movement There are also good studies that show more equipment and intervention = more movement No more standing take-down
What should we do? Place patients on a gurney and secure with the gurney straps The mattress is softer, conforms to the spine better and allows raising the head Higher friction than a backboard There is no downside to using the gurney mattress for transport What do we do in the hospital?
What should we do? For now, use a c-collar, but Not in penetrating trauma to neck Not if airway is difficult to manage If they are alert, just ask them not to move their head Don t need to tape
What should we do? Agitated patients Strapping for EMS personnel safety makes sense Any attempt to restrain a struggling patient with hands, tape, straps will result in maximal force being applied to neck Asleep on their side is better
What should we do? Penetrating trauma Spinal precautions are of no benefit NEVER delay patient treatment for spinal precautions
Thank you!